1942616990 NPI number — PACIFIC INTEGRATIVE MEDICAL CENTER, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942616990 NPI number — PACIFIC INTEGRATIVE MEDICAL CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC INTEGRATIVE MEDICAL CENTER, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942616990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2400 BROADWAY
Provider Second Line Business Mailing Address:
SUITE 520
Provider Business Mailing Address City Name:
SANTA MONICA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90404-3030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-453-8393
Provider Business Mailing Address Fax Number:
310-453-8696

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 520
Provider Business Practice Location Address City Name:
SANTA MONICA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90404-3030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-453-8393
Provider Business Practice Location Address Fax Number:
310-453-8696
Provider Enumeration Date:
07/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
STEFFEN
Authorized Official First Name:
KEELIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
310-453-8393

Provider Taxonomy Codes

  • Taxonomy code: 111NN0400X , with the licence number:  28098 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081S0010X , with the licence number: A108751 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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